Response to “Does Alcoholics Anonymous Work” published by The Conversation

I came across an article which criticizes AA using the in my opinion now-debunked 2014 book by Dodes. I have already dealt with why the Dodes’ figures are suspect in previous blog entries, but to summarize: The figures have been, in my opinion, downright discredited in Cochrane 2020’s report on AA efficacy.

One thing that article does is point to a study which “proves” that alcoholics can control and moderate their drinking. One thing to keep in mind is that while it’s pretty easy to find a study which shows that out-of-control alcoholics claim they are controlling their drinking, those studies are generally short term and based on self-reported data. The last time we had a real long-term study was the 10-year follow-up in Pendery 1982, a famous (if old) study showing that alcoholics do not successfully control and moderate their drinking over a long time period.

But, interested, I looked at this meta-study supposedly showing controlled drinking among alcoholics. This meta-study included studies going back to the 1970s. Most of the studies had only short-term follow-ups; there were only two studies with follow-ups longer than two years.

Diving deeper, I looked at the two studies with a final follow-up longer than two years used to support the idea that an alcoholic can control and enjoy his drinking:

• One study with a 3.5 year follow up is Graber et. al. 1988 [1]. N=24 (which is a much lower N than the studies used to support Cochrane 2020) Looking at the study, I observed that while the supposed “controlled drinkers” claimed to be drinking less than the group told to abstain from alcohol, the collaterals (usually, the drinker’s loved ones) reported that the “controlled drinkers” were actually drinking a lot more than the abstinent group: Self-reported data among the abstinent group was 21 drinks a week (collaterals reported less); collaterals reported nearly 41 drinks a week for the controlled drinking group (self-reporting was a good deal lower).

• The other study they used was from back in the 1970s: Caddy et. al. 1978 [2]. I started reading this study before metaphorically throwing it across the room. It looks at alcoholics in the infamous Sobell 1973 study. The very same alcoholics they looked at in Pendery 1982! (To be pedantic, Pendery 1982 only looked at the 20 alcoholics in the controlled drinking experimental group, while Caddy 1978 looked at all 70 subjects across four groups, but still) At this point, I stopped bothering to read the meta-study.

We know exactly what happened to that very same CD-E (experimental controlled drinking) group of 20 alcoholics 10 years later: They weren’t controlling and enjoying their drinking! (4 dead, 8 out-of-control drinking, 6 abstinent, 1 moderately drinking, 1 not located) Despite this, the meta-study, without even mentioning the existence of Pendery 1982, claimed this study showed the controlled drinking group did better than the abstinent group. I can not take seriously a meta-study which uses data based on those 20 people in Pendery 1982 to argue an alcoholic can control and enjoy his drinking.

If we throw out the data based on the subjects in Pendery 1982, we are left either with studies whose final follow-up is at most two years after treatment, or with the all of 24 subjects in Graber et. al. 1988 where the “moderate drinking” (“controlled drinking” as they called it back then) group was apparently drinking a good deal more than the abstinent group, and were, based on their collaterals, being more dishonest about their drinking.

In terms of the N used for long term follow-ups, as a point of comparison, the Match study used by the Cochrane group in their 2020 AA report had, at the three year follow-up, 952 subjects.

To address the rest of that article, to use Dodes’ questionable figures to conclude AA has a low success rate, and then compare that to a figure that, as it turns out, considers 12-step fellowships a part of mainstream treatment to imply AA isn’t “mainstream treatment” is straight up bad science.  [3] The article tries really hard to downplay the results of Cochrane’s 2020 report on Alcoholics Anonymous: After claiming TSF (which, yes, gets people in the rooms of AA where the real recovery starts) isn’t more effective than other treatments, the article finally contradicts itself in the next sentence by conceding that 12-step oriented therapies increase abstinence, but hedges this by stating “the goal of 12-step facilitation therapy is always abstinence, while other therapies may support a goal of controlled drinking or harm reduction for some heavy and dependent drinkers”; never mind that the article wasn’t able to provide a compelling case that controlled drinking is a workable long-term solution for alcoholics (it isn’t, as I already detailed earlier in this post). Did I mention that this article doesn’t even try to address the multiple observational studies showing that regular AA meeting attenders are twice as likely to get and stay sober?

(I originally posted this on Reddit)

[1] “Abstinence or controlled drinking goals for problem drinkers: A randomized clinical trial” 1988

[2] “Individualized behavior therapy for alcoholics: a third year independent double-blind follow-up” 1978

 [3] The science in that article gets worse. The article links to AA’s 2014 membership survey pamphlet stating that, since 27% of people in the survey are in their first year, this shows a 73% relapse rate. Actually, what the pamphlet shows is that 27% of members are in their first year, and 73% have one year or more sober—quite the opposite of a 73% relapse rate. Like I said, bad science.

More on Pendery 1982

Pendery 1982 is a study which saw that, over the long term, alcoholics who try moderate drinking only have a 5% success rate. People who want to moderately drink again, of course, want to invalidate the results of this study. One attempt at doing this is to complain that Pendery 1982 only looked at the 20 alcoholics who tried moderate drinking in the 1970s Sobell study, and did not look at the alcoholics in the abstinence only control group. For example, “Pendery reinterviewed the controlled drinking group to dispute a previous study but didn't make contact with the abstinence group at all [...] If you are inspecting purported results of a study why not investigate all study participants. Why is it OK to investigate only one side” (note that I normally no longer link directly to self-published rants made by an anti-AA pro-drinking proponent, but since they have subsequently deleted their account, I can do so without making the discussion personal).

This is a red herring. If there was a real methodological problem with Pendery 1982, why did Science (one of the most prestigious journals out there) publish it? The abstinent “control” group was not studied because they were not relevant; if a follow-up study can invalidate the experimental condition (as Pendery 1982 did), there is no need to see what happened with the control condition.

Philip Abelson, the editor of Science when Pendery 1982 was studied, had this to say about the process of making that report:

The report that we published in our 9 July issue [Pendery et aI., 1982] was very carefully edited. It was extensively reviewed, including evaluation by an expert statistician. [...] We required that assertions made about patients' histories be documented by court records, police records, hospital records, or affidavits. The final draft was checked repeatedly, sentence by sentence, to ensure that supporting evidence was available. In crucial instances, two or more independent documents corroborated statements made.

Now, let me describe Philip Abelson in more detail: He helped in the research which won the 1951 Nobel Prize in Chemistry. He won the National Medal of Science in 1987. He was part of the Manhattan Project. He was a key researcher in the design of the nuclear submarine. He did a lot of important paleobiology research. He had over 40 years of experience in the scientific technique when he allowed Pendery 1982 to be published. If there was a real problem with the science behind Pendery 1982, he would had found it.

Some history behind Pendery 1982

Let me finish off 2018 by taking about how the seminal work refuting the notion that alcoholics can moderate their drinking again, Pendery 1982, came to be published.

Pendery 1982 (i.e. M.L. Pendery, I.M. Maltzman, and L.J. West. "Controlled Drinking by Alcoholics? New Findings and a Reevaluation of a Major Affirmative Study" Science 217) is a very key paper in the history of alcoholism studies; the release of the paper was the last nail in the coffin that alcoholics can engage in sustained controlled drinking again. It humiliated the controlled drinking for alcoholics proponents; the study undeniably shows that alcoholics who try moderate drinking end up either dead, drinking like an alcoholic, or abstaining from alcohol.

The paper has a very interesting history which can be seen in two articles from 1982, when this very important paper was published:

• Alcoholism study under new attack. This article shows how the 1970s Sobell studies resulted in alcoholism experts from that era believing that alcoholics could learn to drink in a responsible manner, and how Pendery 1982 refuted that notion.
• Showdown nears in feud over alcohol studies. This article shows how hard Pendery and Maltzman had to work to make their paper a reality: “At every step of the way the Sobells have tried to block the investigation by Dr. Pendery and Dr. Maltzman. [...] The Sobells refused to hand over their list of the participants [...] Undaunted by the Sobells' resistance, the Pendery group tracked down a list of the patients' names at a county alcoholism center [...] The Sobells retaliated with a suit to block the use of the names, but a Federal District court dismissed their action in April 1977 [...] It took Dr. Pendery, using thousands of dollars of her own money and whatever time she could squeeze in among her other obligations, several more years to track down patients”

However, despite all this resistance, the paper was published and the notion that alcoholics could control their drinking again was no longer mainstream addiction research. 60 Minutes broadcast a segment describing the Pendery paper; Al Gore, long before he became vice president, wanted to investigate the Sobells for fraud.

Ultimately, the addiction experts who supported Sobell’s point of view would appear to have never let go of Pendery 1982. As recently as 2015, in a poorly researched anti-AA polemic, Glaser inaccurately describes the Sobell study. The Sobell study was not accurate; while an initial 1982 panel felt the Sobells were reasonably accurate in their research, a later 1984 Federal investigation (you know, with subpoena powers) pointed out that the Sobells were “careless in preparing their manuscripts for publication”. Indeed, some of the “controlled drinking” subjects in the study sued the Sobells.

Since people who think alcoholics can drink moderately again bring this up: How the alcoholics given abstinence treatment fared is a red herring. The Sobell study was done in the early 70s, some four decades before we starting finding twelve step facilitation treatments which effectively got more people going to 12-step meetings and abstaining from alcohol.

The fact of the matter is this: With one exception, Pendery 1982 shows us that the supposedly moderately drinking alcoholics in the Sobell study were either dead, engaging in out of control drinking, or were abstaining from alcohol 10 years later.